Receiving.

Presented by Aimee Nefcy, MD

Case

An 18-month female is brought to the ED by her parents, who state that less than one hour ago they took some coins away from her. They think she may have swallowed one of the coins.  There is no history of gasping, choking, or coughing, and they deny any drooling or crying. No fever, nausea, vomiting, or diarrhea. The child is refusing to drink fluids, but otherwise seems like her normal self

ROS: negative except for as noted in HPI.

PMH: bronchiolitis at age 6mo and hearing impairment

Birth history: full-term, uncomplicated vaginal delivery, birth weight 3.7kg

Meds: none, Allergies: NKDA

FH: asthma in her father

SH: no smoke exposure, does not attend daycare, working smoke detectors

PE: vitals: T 36.8, HR 104, RR 28, Pulse ox 99% RA

General: WN/WD, smiling, playful, active in room

HEENT: PERRL, EOMI, no conjunctival pallor/injection, clear TMs visualized B/L after removal of hearing aids, no nasal discharge, MMM, throat no erythema/exudates, no CLAD, no tenderness to palpation of neck, which is supple. No FB is visualized on examination of the throat.

Respiratory: no tachypnea/retractions/nasal flaring, lungs CTA B/L, no wheezes/stridor/rhonchi/crackles.

Cardiac: RRR, S1 & S2 heard, no M/R/G, pulses 2+ and symmetric

GI: +BS, soft, NT/ND, no masses/organomegaly

GU: normal external genitalia, no lesions/erythema

Musculoskeletal: no cyanosis/clubbing/edema, limbs are atraumatic/nontender

Neurological: cranial nerves grossly intact, no sensory or motor deficits

Skin: warm and dry, no rashes

An x-ray is obtained and is shown below.

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Questions

1) Based solely on the x-ray, the most likely location is?

a. cannot tell without a lateral view

b. esophagus

c. oropharynx

d. stomach

e. trachea

2) What is the most appropriate course of action?

a. attempt direct visualization by laryngoscopy after appropriate sedation

b. oral fluid challenge and discharge home if tolerated

c. repeat x-ray at 12-24hrs post ingestion to make sure it has passed into the stomach

d. stat surgery consult for emergent endoscopy

e. surgery consult for admission and endoscopy in the morning

3) Which of the following excludes an expectant course of action in foreign body ingestion?

a. an asymptomatic patient

b. an object 5cm long in the stomach

c. an object still in the esophagus after 20hrs

d. a patient suspected of body packing with positive x-ray findings

e. a linear cluster of small, round objects in the small intestines

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